A ‘better’ alternative?

Like many, you may have been unwittingly seduced by the relaxed public health stance to vaping, the case being built (or afforded protection from scrutiny) on the basis of the lack of tar and carbon monoxide. Let’s look at this from another angle, though. E cigarettes are addictive and include components with properties that, were they marketed as a new drug would never be licensed: pro-inflammatory and proteomic effects on the airway; increased bacterial adherence; hypersensitivity, the list goes on. In combination these are as destructive as ‘old fashioned’ tobacco in terms of production of emphysema in a murine model.

From the perspective of protecting the health of young people, these data alone raise red flags and collectively show clear breeches of the European Tobacco Products Directive which prohibits the addition of compounds which pose a risk to human health, either when heated or not. As Bush and colleagues’ blistering, compelling attack on the chameleonesque industry suggests, society has been and continues to be duped. This has to be read and is my editor’s choice for the month. See page 1027.

Hearing loss: the subtle end of the spectrum

The effect of severe hearing loss on speech is well recognised but what is less clear is whether common, subtle defects predict school performance. Wang and colleagues sought to address this gap in serial cross-sectional analysis of data collected at 11 to 12 years of age in children enrolled in the Longitudinal Australian Cohort Study. Effect sizes (by SD reduction) for 1483 children with ‘mild’ hearing loss (threshold of 16 to 40 decibels hearing loss (dB HL over the 1 to 4 KHz range)) in relation to National Assessment Programme—Literacy and Numeracy, language, teacher-reported learning, parent and teacher reported behaviour and self-reported quality of life. Of the total, 9.2% and 13.1% had slight/mild bilateral and unilateral hearing loss, respectively. Per SD increment in better ear threshold predicted worse scores in reading (0.11 SD (95% CI 0.05 to 0.16)), parent-reported behaviour (0.06 SD, 95% CI 0.01 to 0.11), physical (0.09 SD, 95% CI 0.04 to 0.14), psychosocial skills (0.06 SD (0.01 to 0.11) and sentence repetition (0.2–0.3 SDs.

What does this mean in practice? The data are cross sectional so inference must be guarded, but the association plausible. Do we need to wait decades for longitudinal data or is screening warranted. If so, how often? When does one start? And then, if ‘positive’, how does one intervene: aeration tubes, amplification or simply positioning a child closer to the teacher? Amazing how little we really know. See page 1056.

One step for a surgeon

This month’s Voices piece is one of the history series. In it Mazurak chronicles the moving background to the world’s first patent ductus arteriosus surgery by Robert Gross in Boston in 1938. As is typical of such advances, this leaps of faith and bravery on both personal and professional levels and, though the operation marked a great step forward for medicine, cost Gross the relationship with his erstwhile boss. See page1096 .

Regulatory ‘problem’ or variant?

Human babies are born at a more immature, more dependent stage of development than their animal counterparts and, as a result, require greater postnatal adaptation. It is likely that the constellation of symptoms collectively known as regulatory problems (RPs) are symptomatic of a delay (or a re-routing) of this process. Normal features (crying, poor sleeping and reluctance to feed) become pathological in excess, but what, if any are the long term consequences?

To explore the relationship between early and late RPs further, Olsen and colleagues followed 3253 infants born between 1 June 2010 and 31 March 2013 in Copenhagen, Denmark, visited by a Community Health Nurse at birth and a year. A fully adjusted model adjusted for socio-economic anD perinatal factors showed 3.36 (1.74 to 6.49) an association which was stronger in boys. Other independent predictors included maternal schooling of less than 10 years and parental birth outside Scandinavia. They conclude that early RPs suggest early neuroregulatory vulnerability trait an issue discussed in detail by

Wolke’s accompanying editorial. The lack of self-control in this group requires more consistent external control to nurture self-regulation. These measures, though easy to prescribe, are, of course, not always easy in the throes of sleep deprivation. See page 1022 and 1034.